Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Wednesday, June 20, 2007

Cold Comfort

I've never hugged a bear, but I'm glad there are bair huggers. Because there's one way in which I'm in major conflict with my patients: I like it cold in the OR. They need it warm. Like the dual-control electric blanket that may have saved my marriage, heating devices in the OR allow dichotomy; the patient can be kept toasty while the surgical folk remain cool. Cooler.

Anyone who's arrived in an operating room awake enough to recall the experience is likely to have noticed it was cool as the frost on a champagne glass (some may know the rest of that one...) "Yeah, we're trying to cut down on heating bills," I'd say when a patient mentioned it. But the fact is, it's personal: it gets darn hot under surgical gowns, especially the newer water-proof ones. Add a little stress, a little anxiety, and a warm room becomes destructively uncomfortable. Nor is sweating a good thing. Dramatic and surgeon-affirming as it may be to ask the nurse to wipe one's brow (I've done it many a time: I find it more embarrassing than off-getting), dropping a bead or two into a wound is poor form. Not that you'd think it necessary, but there have been studies. I've asked more times than I can count to cool a room down. Some ORs have a a sort of power-cool mode, which is like a gift from above. I don't think I've ever complained about a room being too cold: my idea of perfection is seeing the anesthesia person wearing an extra gown and a towel around the neck. Seeing their bare feet in a pan of hot water would likely elicit chills of joy.

Unfortunately, it's also true that letting a patient get cold in the OR is a bad thing. A common explanation for the icy room used to be that it reduces infection. But it's been well-shown that when a patient's core temperature drops, wound infection goes up. And when there's low humidity, there's more static electricity, which (theoretically) can lead to explosions with some of the anesthetic gases. Plus, it's said that particulate matter floats around more easily in dry air. So rooms are kept on the muggy side, making it feel warmer.

Blowing warm air through a flexible hose connected to a puffy air-blanket with holes in it, segmented sausages of soothing sunniness, the bair-hugger keeps people comfy. It was originally a total-body cover, laid on as soon as a patient made it into the recovery room (where people used to arrive, frequently, shivering.) Now there are ones shaped in such a way as to lay across the chest and arms, or the legs, with adhesive strips to keep them in place, and they're becoming almost universal in operating rooms. Perfect. Warm patient, cold surgeon. Crank up the cooler, Carly: I'm goin' in.

[Note: not only do I have no connection to bair-huggers or their company stock, I'm using the term generically, like "kleenex" or "xerox." I'm pretty sure there are other companies and names for similar items.]

21 comments:

That works everywhere except the C-section OR's where the OB types are constantly battling the NICU crowd. Yes, we're roasting under the warmer, so chilling the room would be nice, but we have to think about the baby - for whom that blasting heat often isn't enough.

Good thing C-sections are relatively short surgeries.

OTOH, if I'm having surgery myself, I sure don't want the surgeon passing out from the heat and I'd rather not freeze while I'm sleeping - so great solution in the main ORs.

I like the OR room cold too, but the patient's lose a lot of heat by having the room below 70 degree (if the OR time is greater than one hour). There is a great article on the hypothermia patients often get and how to prevent it (Prevention of Perioperative Hypothermia in Plastic Surgery by V Leroy Young, MD and Maria Watson, MD; Aesthetic Surgery Journal, Sept/Oct 2006, pp 551-571). The minimum OR temperature recommended is 22 degrees Celcius (71.6 degrees F). I know to us surgeons that feels very warm. I now try to keep the room at least at 70, and then just roll up my scrub pant legs (heh, cropped pants are in, at least for us females)

Yeah, something about having one's abdomen ratcheted open in a cold room doesn't do well for one's internal thermostat. I thought it was the coolest thing (ha, punny!) that the anesthesiologists use insulating socks for the IV fluid bags, too.

I don't think anybody who's been truly suited up in the OR could stand anything less what the normally-attired person would consider frigid. I am, unfortunately, an easy "sweater."

There are many compelling reasons to keep the OR warm and to actively warm the patient well during surgery.A few really important ones include hypothermia-induced coagulopathy and subsequent bleeding, and increased oxygen consumption with postoperative shivering (not desirable in the fragile 80 year old with coronary artery disease).I know a surgeon who wears a special vest while scrubbed, which circulates cold water through a system of tubes attached to the vest...I wonder if it's patented...

Anonymous: thank you for asking. You're the first to comment. I could describe them in volumes. Lori is my brother's daughter; Shanti, the daughter of my wife's sister. Each was an amazing young woman, the kind that everyone felt was their best friend; the kind that made everyone happy to be around. They were each amazingly beautiful; head-turning. Each exuded a love of life and of the people in their lives to an extent far beyond the norm. They each died in their twenties, suddenly, unexpectedly, leaving their families devastated. An accident, a blood clot. I could go on without end.

My sole experience with ORs is for c-sections. And though I did notice the cold, I was brought up on the theory that it reduces infection, so it did not seem unusual to me, and in all honesty it was the least of my concerns both times. (Not emergency sections, but I wasn't happy about it either time.) I only got shivery in the recovery room after the second one.

"Who are Lori and Shanti - the women whose headstones are on your front page?"

I'm so glad Anon asked. I've long wondered about who they were as well but was too chicken to ask for fear of being rude. How terrible to lose people so young and full of life. Please accept my heartfelt sympathies, Sid.

Hi Dr S. - I'm with Lynn and wondered but didn't want to ask either. They sound like they were lovely girls.

Personally, I love the cold because I get hot too easily and then I am miserable.

I did notice how cold the pre-op and OR areas were. Of all the procedures I had last year, In May I woke up freezing in post-op and it felt like to my core. I needed more blankets and still was cold. It wasn't even my longest time in the OR, so I don't know why that happened.

I haven't done an actual study, but from what I've seen in the past 11 years in vet med, most of our patients (who generally have plenty of fur that you'd think would keep them warm) drop their temp the most in the period between premedding and induction. There's nothing more lovely than to slap a bair hugger on them prior to draping, and see their body temp rise to normal while intra-op.

Dr. Schwab, I've just found your blog and totally love it. As a veterinary epidemiologist interested in surgical procedure (both animal and human) I was intrigued by when you mentioned that static charges could in theory spark an explosion of inhalational general anaesthetics . . . but I thought these agents like halothane have almost totally been removed from human surgery in the US and western Europe since the early 1990s as better agents that won't go boom came into being? So are static charges still a problem?

anon: you are right. Which is not to say the rules are logical, of course: I refer to OHSA rules, by which (I might be wrong, but I don't think so) humidifiers are required to maintain a specified level. I know that to be the case at least for surgical centers.

Interesting. I had sugery a couple of months ago and noticed that the OR was very cold when I was wheeled in. I actually liked it (I'm always on the warm side, anyway). They did put a warm blanket over me before knocking me out though. When I woke up in recovery I had no blankets and the nurse had removed my socks. She said I was very warm and sweating when I came out of surgery. Go figure.

About Me

I'm a mostly retired general surgeon. With my surgical blog, my intention is to inform, entertain, and possibly educate the reader about surgery, and about the life and loves of a surgeon: this one, anyway. Don't know what I'm thinking, doing a political blog, too.
In an amazing coincidence, I've also written a book, "Cutting Remarks; Insights and Recollections of a Surgeon." It's about my surgical training in San Francisco in the 1970s, aimed at the lay reader with the goal of entertaining with good stories, informing with understandable details of surgical anatomy, procedures, and diseases. Knowing you, I bet you'd enjoy it. In fact, if you like Surgeonsblog, you'll absolutely love the book!

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.